• Rheumatoid Arthritis

What is RA?

  • An autoimmune disease rheumatoid arthritis
  • Unknown etiology
    • Genetic factors (represent 15–70% of developing RA)
  • Generally presents with arthritis

Joints Involvement (Arthritis)

  • Usually presents with the insidious onset of pain and stiffness of the small joints of the hands and feet.
  • The pain is persistent
  • Mainly affects the fingersjoint involvement in rheumatoid arthritis
  • In 25% of cases RA presents as arthritis of a single joint (e.g. knee): May mimic clinical feature of Lyme disease or a spondyloarthropathy.
  • Usually present as polyarthritis:
    • Hands: MCP, PIP, DIP joints
    • Feet: Ankle, MTP, Tarsal joints (not IP joints),
    • Cervical spine (not lumbar spine)
    • Wrists
    • Elbows
    • Knees
    • Hip (delayed)
    • Shoulder (glenohumeral) joints
    • Temporomandibular joints

Important Health Concern

  • Most common chronic inflammatory polyarthritis (affects about 1–2% of the population.
  • Expression: Vary from a mild to a most severe debilitating
    • More than 10% of patients have a relentless progression and require aggressive drug therapy.



  • Usually Insidious onset. Can begin acutely (explosive type)
  • Age of Onset
    • Any age 10–75 years
    • Peak 30–50 years
  • Gender
    • Female to male ratio = 3:1rheumatoid arthritis 03
  • Joint pain
    • Worse with waking
    • Nocturnal pain interfere with sleep
    • Relieved with activity
  • Morning stiffness (can last a couple of hours)
  • Rest stiffness (e.g. after sitting)
  • General:
    • Fatigue
    • Malaise
    • Weakness
    • Weight loss
  • Disability according to involvement


  • Effusion and synovial swelling especially of wrist, MCP and PIP joints
  • Limited ROM
  • Warmth
  • Tenderness of joints
  • Muscle wasting
  • Advanced stagerheumatoid arthritis 02
    • Instability
    • Deformity (Swan necking, Boutonnière and Z deformities)
    • Subluxation: include atlantoaxial subluxation
    • Ankylosing
  • Impaired a number of everyday functions such as
    • Precision grip (using a key or pen)
    • Hook grip (carrying a bag)
    • Power grip (lifting a jug of water)

Non-Articular Manifestations

  • Anemia
  • Amyloidosis: mainly kidneys
  • Sjögren Syndrome: Dry mouth, Dry eyes
  • Vasculitis: Skin Ulcers, Purpura
  • Pulmonary Involvement: Pleural Effusion, Fibrosing Alveolitis, Nodules (Caplan Syndrome)
  • Cardiac Involvement: Myocarditis, Pericarditisrheumatoid arthritis 04
  • Inflammation of the Eyes
  • Lymphadenopathy
  • Splenomegaly (Felty Syndrome)
  • Musculoskeletal Involvement: Bursitis, Subcutaneous Nodules, Bakers Cyst, Tenosynovitis, Carpal Tunnel Syndrome (CTS)
  • Peripheral Nerves Involvement: Polyneuropathy, Mononeuritis Multiplex
  • Raynaud Phenomenon

Diagnostic Criteria

  • Symptom duration more than 6 weeks
  • Early morning stiffness more than 1 hour
  • Arthritis in three or more regions
  • Bilateral tenderness of the metatarsophalangeal (MTP) joints
  • Rheumatoid factor (RF) positivity
  • Anti-cyclic citrullinated peptide (Anti CCP) antibody positivity
  • Symmetry of the areas affected
  • Bony erosions evident on radiographs of the hands or Feet (usually in late stages)


  • Anemia: Usually normochromic & normocytic
  • ESR/CRP: Usually raised according to activity of disease
  • Rheumatoid factor
    • Positive in about 70–80% (mainly in late disease)
    • 15–25% of RA patients will remain negative
  • Anti-cyclic citrullinated peptide (anti-CCP) antibodiesrheumatoid arthritis 06
    • More specific for RA (about 95% specificity)
  • X-ray findings:
    • Loss of joint space
    • Erosion of joint margin: ‘mouse-bitten’ appearance
    • Juxta-articular osteoporosis
    • Cysts
    • Advanced: subluxation or ankylosing
  • MRI: Helpful for early diagnosis
  • Important Points:
    • If the RA factor is positive, it is non-specific, so the anti-CCP antibody should be ordered to confirm the diagnosis.
    • RA has a strong cardiovascular risk factor.



  • The patient and family require appropriate reassurance and education support
  • Early induction of disease remission is necessary to reduce
    • Joint damage
    • Malignancy (especially lymphoma)
    • Cardiovascular disease
  • Due to disease progression in the first 2 years
    • Relative aggressive treatment with DMARDs (rather than to start stepwise with analgesics and NSAIDs only) is recommended
  • Team approach is highly recommended
  • Patient’s functional impairment (home life, work, social activity) should be monitored. Family should be involved in decision making


  • Rest and splinting: For acute flare-up of arthritisrheumatoid arthritis 08
  • Exercise
    • Especially walking and swimming
    • Hydrotherapy in heated pools
  • Smoking cessation: Strongly recommended
  • Referring to physiotherapists and occupational therapists
    • Exercise supervision
    • Physical therapy
    • Coping in the home and work
  • Joint movement
    • Daily full range of motion to reduce stiffness
  • Diet
    • Avoiding animal fats (dairy products and some meats)
    • Consumption of fish oil
  • Obesity must be avoided

Pharmacological Treatment

    • Effective but adverse effects are a problem
  • Fish Oilrheumatoid arthritis 07
  • Corticosteroids
    • Oral, Intravenous, Intra articular
  • Disease-modifying anti-rheumatic drugs (DMARDs)
    • Immunosuppressants
      • Azathioprine
      • Cyclosporin
      • Leflunomide
      • Methotrexate
    • Cytokine inhibitors (biological DMARDs)
      • Anti-TNF α agents: Abatacept, Adalimumab, Etanercept, Infliximab, Golimumab, Rituximab
      • Anti-Interleukin-1 agents: Anakinra, Tocilizumab
    • Gold Salts
    • Others
      • Hydroxychloroquine
      • Chloroquine

Other Possibilities

  • Assistive devices and orthoses (footwear, insoles, cane, walker, wheelchair)
  • Orthopedic surgery (joint replacement, synovectomy, plastic hand surgery)

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